<!DOCTYPE html> 
<html> 
  <head> 
  <title>Form submission</title> 
</head> 
<body> 

<div data-role="page">

  <div data-role="header">
    <h1>Sample form response</h1>
  </div><!-- /header -->

  <div data-role="content">
    <h1>Fake response</h1> 
    <h2>You choose: (your value here if it would be no fake)</h2> 
  </div><!-- /content -->
  
</div><!-- /page -->

</body>
</html>